Healthcare Provider Details

I. General information

NPI: 1366258766
Provider Name (Legal Business Name): NICK ALLEN MADDOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W LEOTA ST
NORTH PLATTE NE
69101-6525
US

IV. Provider business mailing address

603 WILDWOOD LN
NEBRASKA CITY NE
68410-3352
US

V. Phone/Fax

Practice location:
  • Phone: 308-568-8000
  • Fax:
Mailing address:
  • Phone: 402-209-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: